Sunday, February 26, 2017

A functional AAC system is a compilation of strategies that allow the individual to communicate effectively a variety of intents in a variety of contexts, with a variety of partners.

We need to recognize that different modes of communication are useful and necessary in different contexts while also remembering that we need to provide users with sufficient vocabulary - in whatever mode- to allow them to communicate genuine messages.

In terms of fostering the most “robust” AAC system, it is important to teach flexibility and have alternative means available for when the primary mode of communication is not practical at that time, or is unavailable for whatever reason: if the high tech device is broken or malfunctioning, for example. In addition, students might need to be able to use different communication modes in different social circumstances. For example, what might seem appropriate with friends in an informal interaction would be totally out of place interacting with a teacher, or in a formal social situation with adults. Similarly, a student who communicates with his familiar classroom aide using signs would need to have the flexibility to communicate via a different mode in the community with individuals who do not understand sign.

We all use a variety of modes of communication; the mode at any given instance being reliant on context and intent. The same should be true of our nonverbal clients and students. In fact, use of multiple component systems has been shown to be more effective and more natural (Erickson).

Any system must provide well organized language, both core and fringe words, and stability of vocabulary and location.

So, when asked the question, “Does this individual need a low-technology system or a high-technology device?” the answer is “Yes. All of the above.” At all times we should remember to focus on the individual and their communication; NOT the technology.

Next week, I'll talk about some of the no-tech to high-tech options. I have a fairly robust communication book in my store at Teachers Pay Teachers that focuses on core vocabulary, but with added fringe vocabulary for a variety of functions and topics. You can find it here.

I also have a variety of topic boards that have core vocabulary as a base, with additional topical vocabulary and messages for purposes of protest, escape, or change. You can find them in the AAC section of my store.

Sunday, February 19, 2017

Communication needs a purpose - an intent. The individual must have something that he wishes to communicate - impart - to someone else. It is important to make situations motivating and meaningful in order to create an environment in which an individual who is just learning to communicate has something he wants to say and the means to say it.

A case in point: I was called in to consult a district regarding a boy of 10 with autism.

He had been using a PECS board with symbols for favorite foods and activities.

Pictures were also used during specific activities in the class. These velcro’d pictures were only available during the specific activity, and were limited to symbols required for that activity. They were also limited to nouns, with a few activity-associated verbs.

They told me he had been successful for a while with pictures, and was great at using them to request food (he was always hungry), but wasn’t using them for other activities and so they did not think he was “ready” for a more complex system.

When I observed in his classroom, I saw him first during an art activity where he was required to cut and paste, then color. This was a boy who had poor fine motor skills and did not like or ever want to do cutting and coloring. But the symbols for the activity required to him say that he wanted scissors, he wanted glue, he wanted the red crayon, etc. He most clearly did Not Want any of these things – and “Not” was not available among the symbols.

Given an activity he enjoyed and appropriate symbols to use, he was clearly able to use them. His vocabulary was limited, as he had always been restricted to a noun-based vocabulary, but he clearly knew what the pictures were for and how to use them.

Lessons learned:

1. Verbal communicators are able to tell you when they don’t want something or don’t want to say what you want them to. Nonverbal communicators have the same right to say “I don’t want to” as everyone else.

2. Only giving the individual the words to say specific, limited messages does not give them the ability to communicate.

3. As Gayle Porter says, “…a child who uses speech will independently select the words she wishes from the vast array she hears/uses every day. A child who uses AAC will independently select the words she wishes to use from the vocabulary other people have chosen to model and, for aided symbols, made available for her to use.” (Porter & Kirkland) And a child who uses a limited AAC system will sometimes NOT choose to select words that do not say what he wants them to.

Sunday, February 12, 2017

For students who face significant motor, visual, hearing, and/or other multiple challenges, or those for whom device use has not been successful secondary to access or consistency issues, flexibility of thought and knowledge of available options are required in order to determine appropriate access.

All communication relies on perception of sensory input and ability to make a physical response of some sort. When looking at an individual’s ability to use AAC to develop communication we have to be aware of how he processes input (what type of atypical patterns are used), how the individual moves (what atypical patterns exist, what movements exist to use for responding), how stable those movement patterns are, and what are the effects are of position stability, motivation, other impairments.

Many of these children are caught even more tightly by the “Catch 22” (Porter) for individuals who require aided modes of communication:

Aided language does not naturally exist in the environment

The individual cannot spontaneously “uptake” something that is not there

Professionals intervene based on their perception of what’s possible

The individual can only demonstrate what’s possible based on what’s been set up to use

Once again, aided language stimulation is a necessary ingredient in the individual's environment for him to be a successful communicator. As he responds to what’s provided the assessment can continue. Dynamic assessment is necessary in AAC. We intervene -> observe -> intervene -> observe (Porter 1997).

Alternate Ways to Respond to AAC Systems

Modified direct access:

Such as a head pointer, mouth stick pointer, eye gaze (all low/no tech)

Partner assisted scanning (PAS):

Uses partners who have been specially trained for interacting. Partners show, point, and/or speak each item.

Eye gaze systems:

Can range from no-tech to the ultimate high tech.

Head mouse, head tracker, joystick, mouse emulators:

Modifications on direct selection using infrared beams or computer access modes. The head tracker is more tolerant of head movement than eye gaze technology systems, but shows greater fatigue.

Use of key guards to count spaces as a tactile guide to the display:

Requires memorizing the displays and sequences.

Switch/scanning:

The slowest way to access an AAC system.

The specific motor impairments of the AAC user need to be assessed and catalogued. What are the effects of muscle strength, symmetry of body, disassociation, ATNR (asymmetrical tonic neck reflex) weight bearing and shifting, eye-hand coordination? Know whether shoulders are forward, elbows flexed or extended. Determine the ability to grasp a target or use vision. Know if there is increased response time. Determine the available movement pattern.

A variety of body parts can be used to activate switches. Head switches can include toggle-type switches, button-type (such as Jelly Bean and Buddy Button), head, chin, and tilt switches. The Sip ’n Puff switch is used in the mouth. There are also foot switches and eye blink switches. Some very sensitive switches can be activated by very minimal muscle movement. For using the hand, beyond standard button switches, there are finger, thumb, and pinch switches, as well as switches that use hand grip.

For some users the size of the target area is crucial. Some individuals need a larger switch for consistent access, such as Jumbo and Saucer switches.

For other users the range of motion needed to find and hit the switch is of utmost importance. Switches that work well with individuals who have limited range of motion or limited fine motor skills include the Twitch, Finger, Compact, and Gumball switches.

For users who require sensory feedback from the switch there are switches that provide vibration, textured surfaces, lights, or music. For users with visual impairments there are switches that offer color, contrast, lights and vibration.

There are a variety of access possibilities. It takes time, knowledge of the individual, and knowledge of his communication needs and environments.

Sunday, February 5, 2017

Did you know February is Vision Awareness Month? If you’re a speech-language pathologist or teacher working with students with cerebral palsy or other brain-based disabilities, chances are you have a student with C.V.I.

Vision, more than any other system, allows the individual to take in huge amounts of stimuli from the environment for the brain to act upon. In the process, the individual gazes at things, does so in specific sequences, and focuses on specific details in order for the brain to make decisions about what to do.

Vision develops as a process of neurological development and maturation. Our ability to process visual stimuli and attach meaning to them - called “seeing” - involves not only a healthy vision system, but also a healthy neurological system.

When a child is born with a neurological disorder, it is likely that a visual impairment will exist. Development of the visual system, learning through interaction with the environment, is also impaired when a child has motor impairment. Eyes do not tell the individual what to do. The brain’s experiences do. Without these experiences, or when the experiences are impaired in some way, the brain cannot tell the individual how to act and react.

“The current leading cause of visual impairment among children is not a disease or condition of the eyes, but Cortical Vision Impairment (CVI) - also known as cerebral visual impairment - in which visual dysfunction is caused by damage or injury to the brain.” (American Printing House)

Cortical vision impairment has nothing to do with acuity. It is vision impairment caused by damage or injury to the brain.

Because the areas for vision in our brains are not just localized to one small area, chances are if there is any brain damage at all that some aspect of vision in the brain is impacted.

CVI can be found in individuals who have had a head injury, brain infection, brain maldevelopment, or asphyxia.

There are some specific characteristics of CVI; including color preferences, attraction of movement, response latency, reduced visual fields, difficulty with complex visual stimuli, gazing at lights or at nothing at all, reflexive responses to visual stimuli, attraction to novel visual stimuli and visual-motor mismatch.

Cortical vision impairment is the most common cause of vision impairment in children in the U.S. It is seen in children who are premature, who have a neurological disorder, or have had acquired brain injury. Given that 40%-80% of the brain is required to process vision, brain damage in almost any area can lead to CVI. The brain loses its ability to integrate and organize visual input received from the eyes.

Improvement is both possible and likely with training. This requires discovering the CVI at an early age and providing direct intervention. (Roman-Lantzy, C., 2007) Children with CVI have the capacity to see more effectively and can learn effectively given an adequate plan and intervention.

In general, individuals with CVI experience success with AAC systems that utilize partner assisted scanning; tactile systems with voice output; auditory scanning high tech voice output devices; and two-switch auditory step scanning where the user can control the speed of scanning for processing, that utilize visual tracking of a visual stimulus across the scan (such as a flashlight or finger or bright object).

Burkhart also suggests “using a communication device (BIGmack Communicator) using color coding. For example pair a 2D picture with a similar 3D object using bright colors. Have the communicator in the same color (i.e. Have a picture of a red cup, have a red cup and a red communicator that says, ‘I want a drink,’ when accessed.”

Additional tips for AAC use with these students include:

Use Partner Assisted Scanning or use devices with auditory scanning. These modes of access allow for success by removing the need to visually attend to and shift from pictures the students can’t see; there is now no need for communication success to be dependent upon symbol recognition.

Abandon the kind of standard objectives you set for other AAC users. These students will have difficulty or lack of success with objectives to match objects to pictures, make requests using picture boards a specified number of times, or identify named pictures in arrays. Matching and identification tasks are largely nonfunctional, anyway.

Avoid vocabulary that only relates to a single activity and then doesn’t get used again; use of core vocabulary or high frequency vocabulary is beneficial for these individuals.

Avoid limited choices that don’t allow engagement. This is true for many students. Multiple choice responses do not encourage language development or elaborate interactions.

Provide social contact vocabulary so that the individual can maintain social interaction and engagement with others, even when unable to see what is going on.

Provide vocabulary that is stable and can be added to as skills develop. This, again, encourages the use of core vocabulary, where words have multiple meaning uses with a limited number of visual distinctions.

Provide vocabulary sets that are organized and stay the same each time.

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